Hernia
A hernia is a weakening, or a bulge or protrusion through an area of the abdominal wall, either in the groin or along the upper abdominal wall. The area of weakness can be caused by a previous surgery or it can be caused by a natural opening or weakening that body has as a result of normal develpment.
There are multiple types of hernias. 99% of hernias are either hiatal hernias, abdominal wall hernias, or groin hernias. Hiatal hernias are discussed in the section that is labeled Gastro-Esopageal Reflux Disease. Groin hernias are usually in men. The hernia develops as as a result of a natural weakness men have as a result of where the testicle descended into the scrotum. This weakness can later manifest itself as a hernia or a bulge during coughing or straining. Abdominal wall hernias are also called ventral hernias. These are usually the result of a previous incision, or they are located in the ‘belly button’ region.
To see video on a Hernia operation, please click here.
SYMPTOMS OF A HERNIA
Symptoms of hernias can vary. Usually the onset of symptoms is very gradual, and often times, people do not have symptoms at all. Many times, however, people present themselves to the doctor after noticing a sudden bulge, or experiencing sudden pain, or sudden change in presentation, usually after lifting heavy equipment or heavy objects. They can also present with repeated attacks of coughing or straining to urinate or anything that causes increased abdominal wall pressure. Chronic constipation or difficulty defecating can also bring on the symptoms of a hernia.
In most cases, however, these aforementioned activities, are usually “the straw that breaks the camel’s back”, because the hernias have usually been present for quite some time before that central event.
Surgery for hernias is usually not an emergency. It is an elective surgery, and it can be an elective surgery as long as it is not incarcerated and causing pain. When a hernia bulges, sticks out, and one is unable to push the bulge back in and be pain-free, it could be a sign that there is vital intra-abdominal structure that is having blood flow and blood supply constricted, and that area of tissue can die. These types of situations are emergencies, because if you have something like your intestines stuck in a hernia and it cannot get back inside your abdomen, the area of intestine can die, and it can be a fatal event.
For these reasons, if you do have a bulge that is unable to be reduced and you are having constant pain, changes in skin color, or if the area is tender, you should seek medical attention immediately.
Inguinal Hernias
Groin hernias, or inguinal hernias, are the most common sites of a hernia. Although they do occur in women, the overwhelming majority of hernias occur in men. At BMI of Texas, we prefer to repair groin hernias laparoscopically. By performing these repairs laparoscopically, it leads to reduced pain and it allows people to return to work much more quickly. In addition, a laparoscopic approach allows one to examine both the right and left sides where hernias could form, and this is an advantage, because it also can prevent wrong site surgery. The locations of the incisions are exactly the same, whether or not the groin hernia is on the left or right.
There are several different types of groin hernias. Groin hernias can be direct inguinal hernias, indirect inguinal hernias, or femoral canal hernias. All of these types of hernia can be repaired laparoscopically. One does not necessarily know what type of groin hernia they have until the surgery is over. Knowing what type of hernia someone has is really not important before surgery.
When we repair groin hernias, we use “mesh”. Mesh is like a screen on a door. It looks like ‘netting,’ and it has sort of almost a fiberglass type appearance to it. This netting or mesh acts like a ‘scaffold’ on a building. When the mesh is placed in its proper location, it is tacked into place using a combination of sutures, as well as some titanium staples, and the body grows into the mesh like a scaffold on the side of a building, and it forms a scar that is much more durable and stronger than what our bodies normally could create.
Typically, laparoscopic hernia repairs take under an hour, and when surgery is over, we generally have our male patients wear a jock strap or an equivalent for at least 2-3 weeks, and we ask them to keep the scrotum elevated whenever possible to reduce any discomfort, as well as reduce any potential swelling that can occur. In addition, we utilize the ON-Q pain ball soaker system to provide outstanding pain control, and this allows people to get back to work much more quickly. There are no restrictions on diet or exercise after laparoscopic groin hernia surgery.
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VENTRAL HERNIAS
Ventral hernias like groin hernias are abnormal protrusions or weaknesses through a weakened area in the abdominal wall. Weaknesses of the abdominal wall usually occur at the “belly button” or what is called the umbilicus. However, an overwhelming number of abdominal wall hernias, occur at previous incision sites, which are natural areas of weakness. When someone has surgery and you close the abdominal wall back up, it never is able to reach 100% of the strength it had before surgery. For these reasons, these areas of weakness can turn into hernias. Hernias along a previous incision usually have a “Swiss Cheese” appearance on the inside, even though you may only be experiencing one specific bulge. People are always surprised to find out that ‘one’ hernia can often actually be 10 to 15 small hernia defects.
Ventral hernias are best treated laparoscopically. Usually through 3 or 4 small incisions, we are able to not only to clean off the entire abdominal wall, we are also able to introduce mesh into the abdomen to act as a scaffold, so that a much more durable, scar can form. The mesh that is used on the abdominal wall is much like the mesh used in the groin, except it is usually of a different material that is appropriate for intra-abdominal placement.
Hernias of the abdominal wall can be very, very complex, especially, if the hernia goes below the level of the belly button or umbilicus. Ventral wall or abdominal wall hernias can be repaired laparoscopically and these operations are fairly painful. The reason that they are painful is because we use a combination of absorbable screws and sutures to keep the mesh from migrating. It is very important that if you are seeing a surgeon about an abdominal wall hernia repair, to be performed laparoscopically, that they incorporate both techniques of what is called a transabdominal fixation, as well as “tacking.” These two techniques must be employed to ensure an adequate sturdy repair to keep the mesh from migrating.
The size of the mesh that is used can be surprisingly large at times. The mesh must have a significant amount of overlap, because the mesh can often shrink in size.
Just like groin hernias, with abdominal wall hernias we also utilize the On-Q pain ball catheter system for superior pain control. After surgery, one wakes up with a pain ball and this ball is kept in place for several days, to ensure adequate pain relief.
PREPARING FOR GROIN HERNIA SURGERY
There is really no medical treatment for hernias. Hernias need to be treated surgically. They will not heal spontaneously on their own. Generally hernias will increase gradually over time. Most groin hernias are repaired on an outpatient basis.
Complications of groin hernia surgery include infection and bleeding, which occurs any time you have an operation. There is approximately a 1% or less chance of having a hernia recurrence, where the hernia surgery fails. For men, one can have injury to the testicle, vas deferens or to the spermatic cord and its associate vessels. It is also possible that one can develop chronic pain, numbness, or requirement for future surgery.
RECOVERY Inguinal Hernia
After your groin hernia surgery, you typically go to Recovery Room for 1 to 2 hours, where your anesthesia wears off. At that time, the staff makes sure that you can ambulate and urinate. When you have a good handle on your pain control, you are discharged from the surgery center. Most people are able to gradually return to their activities of daily living over the next several days, and it is very appropriate for one to ask for a week or so off. There are, however, no true physical restrictions and you could go back to work right away. It is not uncommon for there to be some bruising or swelling around your testicles, scrotum and penis, and bruising may occur several days or several weeks later, but usually it is painless. We ask you to follow up in our office for your post-op check up, approximately 2 to 3 weeks after surgery. Most patients do avoid any strenuous activity after surgery for the first week or so, but truly there are no physical restrictions.
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RECOVERY Ventral hernia
The recovery from a ventral hernia can be a bit more arduous than an out-patient groin hernia surgery. Laparoscopic ventral hernia repairs often require 1 or 2 nights in the hospital, largely due to pain control. Some narcotics are usually required for at least the first night or so and patient-control analgesia is utilized and patients administer their own Morphine through a pump. Immediately after surgery, you are asked to walk and when we can adequately control pain and you are able to ambulate, you are usually discharged home. This procedure generally requires 1 or 2 nights in the hospital.
Much like groin hernia surgery, there are no physical restrictions after a laparoscopic ventral hernia repair with mesh. Although, the abdominal wall may have many more hernia defects, once the mesh is in place, there are no significant physical restrictions. This is not to say that you will not be very, very sore, because you will be and that soreness may last for several weeks, or a month or more in varying degrees. Rest assured, however, there is nothing that you will do physically that would make the hernia come back or the hernia repair fail. However, you will often feel some pulling, tearing, stretching or “catching” pain at the areas, especially where the 4-sutures are holding the mesh in place. These areas of soreness usually go away, within the first week or so after surgery.
AFTER SURGERY
After surgery, the patients usually see us about 2 to 3 weeks after surgery and during that time, you can certainly go back to work. Everyone has different motivations for returning to work, but it is certainly appropriate to ask for 2 weeks or so of recovery, after your abdominal wall hernia surgery.
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♦ General Surgery